Clear, accurate, and accessible documentation is an essential element of
safe, quality, evidence-based nursing practice. Nurses practice across settings
at position levels from the bedside to the administrative office; the
registered nurse (RN) and the advanced practice registered nurse (APRN)
are responsible and accountable for the nursing documentation that is used
throughout an organization. This may include either documentation on
nursing care that is provided by nurses—whether RN, APRN, or nursing
assistive personnel—that can be used by other non-nurse members of the
health care team or the administrative records that are created by the nurse
and used across organization settings.
Documentation of nurses’ work is critical as well for effective communication
with each other and with other disciplines. It is how nurses create a record of
their services for use by payors, the legal system, government agencies,
accrediting bodies, researchers, and other groups and individuals directly or
indirectly involved with health care. It also provides a basis for demonstrating
and understanding nursing’s contributions both to patient care outcomes and
to the viability and effectiveness of the organizations that provide and support
quality patient care.
Documentation is sometimes viewed as burdensome and even as a
distraction from patient care. High quality documentation, however,
is a necessary and integral aspect of the work of registered nurses in all
roles and settings. This requires providing nurses with sufficient time and
resources to support documentation activities. At a time when accessing,
generating, and sharing information in health care is rapidly changing, it is
particularly important to articulate and reinforce principles that are basic
to effective documentation of nursing services.
It is important to bear in mind that this publication’s focus on nursing
documentation is necessarily more that of a conceptual overview than a
technical summary. The pace of innovation and adoption of the digital
technologies of such documentation requires this. But the attendant issues of
accuracy, confidentiality, and security of patient documentation, in accordance
with regulatory guidelines and mandates, are and will remain paramount,
whatever the technological platform. These enduring issues inform and
underline the principles and recommendations in this publication.